ABSTRACT: The incidence of malignant melanoma has increased in recent years more than that of any other cancer in the United States. About one in 70 people will develop melanoma during their lifetime. Family physicians should be aware that a patient with a changing mole, an atypical mole or multiple nevi is at considerable risk for developing melanoma. Any mole that is suggestive of melanoma requires an excisional biopsy, primarily because prognosis and treatment are based on tumor thickness. Staging is based on tumor thickness (Breslow's measurement) and histologic level of invasion (Clark level). The current recommendations for excisional removal of confirmed melanomas include 1-cm margins for lesions measuring 1.0 mm or less in thickness and 2-cm margins for lesions from 1.0 mm to 4.0 mm in thickness or Clark's level IV of any thickness. No evidence currently shows that wider margins improve survival in patients with lesions more than 4.0 mm thick. Clinically positive nodes are typically managed by completely removing lymph nodes in the area. Elective lymph node dissection is recommended only for patients who are younger than 60 years with lesions between 1.5 mm and 4.0 mm in thickness. In the Eastern Cooperative Oncology Group Trial, interferon alfa-2b was shown to improve disease-free and overall survival, but in many other trials it has not been shown to be effective at prolonging overall survival. Vaccine therapy is currently being used to stimulate the immune system of melanoma patients with metastatic disease.

ABSTRACT: The majority of patients presenting with peripheral lymphadenopathy have easily identifiable causes that are benign or self-limited. Among primary care patients presenting with lymphadenopathy, the prevalence of malignancy has been estimated to be as low as 1.1 percent. The critical challenge for the primary care physician is to identify which cases are secondary to malignancies or other serious conditions. Key risk factors for malignancy include older age, firm, fixed nodal character, duration of greater than two weeks, and supraclavicular location. Knowledge of these risk factors is critical to determining the management of unexplained lymphadenopathy. In addition, a complete exposure history, review of associated symptoms, and a thorough regional examination help determine whether lymphadenopathy is of benign or malignant origin. Unexplained lymphadenopathy without signs or symptoms of serious disease or malignancy can be observed for one month, after which specific testing or biopsy should be performed. While modern hematopathologic technologies have improved the diagnostic yields of fine-needle aspiration, excisional biopsy remains the initial diagnostic procedure of choice. The overall evaluation of lymphadenopathy, with a focus on findings suggestive of malignancy, as well as an approach to the patient with unexplained lymphadenopathy, will be reviewed.

ABSTRACT: Acute interstitial nephritis is an important cause of acute renal failure resulting from immune-mediated tubulointerstitial injury, initiated by medications, infection, and other causes. Acute interstitial nephritis may be implicated in up to 15 percent of patients hospitalized for acute renal failure. Clinical features are essentially those of acute renal failure from any cause, and apart from a history of new illness or medication exposure, there are no specific history, physical examination, or laboratory findings that distinguish acute interstitial nephritis from other causes of acute renal failure. Classic findings of fever, rash, and arthralgias may be absent in up to two thirds of patients. Diagnostic studies such as urine eosinophils and renal gallium 67 scanning provide suggestive evidence, but they are unable to reliably confirm or exclude the diagnosis of acute interstitial nephritis. Renal biopsy remains the gold standard for diagnosis, but it may not be required in mild cases or when clinical improvement is rapid after removal of an offending agent or medication. The time until removal of such agents, and renal biopsy findings, provide the best prognostic information for return to baseline renal function. Corticosteroids appear to provide some benefit in terms of clinical improvement and return of renal function, but no controlled clinical trials have been conducted to confirm this.

ABSTRACT: Pityriasis rosea is a common, acute exanthem of uncertain etiology. Viral and bacterial causes have been sought, but convincing answers have not yet been found. Pityriasis rosea typically affects children and young adults. It is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash. The herald patch often is misdiagnosed as eczema. Pityriasis rosea is difficult to identify until the appearance of characteristic smaller secondary lesions that follow Langer's lines (cleavage lines). Several medications can cause a rash similar to pityriasis rosea, and several diseases, including secondary syphilis, are included in the differential diagnosis. One small controlled trial reported faster clearing of the exanthem with the use of erythromycin, but the mechanism of effect is unknown. Resolution of the rash may be hastened by ultraviolet light therapy but not without the risk of hyperpigmentation. Topical or systemic steroids and antihistamines often are used to relieve itching.

ABSTRACT: Rates of squamous cell and basal cell carcinomas have been increasing, possibly as a result of increased exposure to ultraviolet radiation. Primary care physicians can expect to diagnose six to seven cases of basal cell carcinoma and one to two cases of squamous cell carcinoma each year. Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and telangiectasia. They rarely metastasize and are treated with excision, cryotherapy, electrodesiccation and cautery, imiquimod, 5-fluorouracil, or photodynamic therapy (the latter is not approved for this purpose by the U.S. Food and Drug Administration), although surgery results in the fewest recurrences. Actinic keratoses are scaly keratotic patches that often are more easily felt than seen. They are amenable to any of the destructive techniques described above, with the exception of photodynamic therapy. Squamous cell carcinomas arise from keratotic patches and become more nodular and erythematous with growth, sometimes including keratin plugs, horns, or ulceration. Because they may metastasize, they often are treated with excisional biopsy.

ABSTRACT: The American Society for Colposcopy and Cervical Pathology developed guidelines in 2001 for the management of cervical cytologic abnormalities. The guidelines incorporate the Bethesda System 2001 terminology and data from randomized studies of atypical squamous cells, low-grade intraepithelial lesions, human papillomavirus testing, and liquid-based cytology to formulate evidence-based recommendations. Each recommendation is graded according to the strength of the recommendation and the quality of the evidence, and specific terminology is added to highlight management options. The effectiveness of each triage recommendation is determined by the percentage of grade 2 and 3 cervical intraepithelial neoplasia it detects. Colposcopy, repeat cytology, and human papillomavirus DNA testing are acceptable options in women with atypical squamous cells of undetermined significance, but human papillomavirus DNA testing is preferred if liquid-based cytology is used. Colposcopy is recommended for women with a diagnosis of "atypical squamous cells-cannot rule out high-grade intraepithelial lesion." Women with low-grade squamous intraepithelial lesions should be referred for colposcopy, and women with high-grade lesions should undergo colposcopy and endocervical assessment. Colposcopy and endocervical sampling are recommended in women with all subcategories of atypical glandular cells. Endometrial sampling and colposcopy are recommended in women older than 35 years with atypical glandular cells and in younger women with unexplained vaginal bleeding. Women with a diagnosis of "atypical glandular cells-favor neoplasia" or adenocarcinoma-in-situ who are not found to have invasive disease on colposcopy should undergo a diagnostic excisional procedure, preferably a cold-knife conization.